Provider Demographics
NPI:1932158987
Name:GHANEM, BAHJAT F (MD)
Entity Type:Individual
Prefix:
First Name:BAHJAT
Middle Name:F
Last Name:GHANEM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4445 W 16TH AVE
Mailing Address - Street 2:SUITE 250
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-7189
Mailing Address - Country:US
Mailing Address - Phone:305-822-5964
Mailing Address - Fax:305-822-0058
Practice Address - Street 1:4445 WEST 16TH AVE
Practice Address - Street 2:SUITE 250
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-2900
Practice Address - Country:US
Practice Address - Phone:305-822-5964
Practice Address - Fax:305-822-0058
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0066087208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL373630000Medicaid
FLK9914Medicare ID - Type Unspecified
FLF80184Medicare UPIN
FL373630000Medicaid
FL25108Medicare ID - Type Unspecified